https://jnnp.bmj.com/content/jnnp/41/2/191.3.full.pdf

Pathology of Tumours of the Nervous System.

Principles and Practice of Infectious Diseases

Objective To develop evidence-based clinical practice guidelines for interventional techniques in the diagnosis and treatment of chronic spinal pain. Methodology Systematic assessment of the literature. Evidence I. Lumbar Spine • The evidence for accuracy of diagnostic selective nerve root blocks is limited; whereas for lumbar provocation discography, it is fair. • The evidence for diagnostic lumbar facet joint nerve blocks and diagnostic sacroiliac intraarticular injections is good with 75% to 100% pain relief as criterion standard with controlled local anesthetic or placebo blocks. • The evidence is good in managing disc herniation or radiculitis for caudal, interlaminar, and transforaminal epidural injections; fair for axial or discogenic pain without disc herniation, radiculitis or facet joint pain with caudal, and interlaminar epidural injections, and limited for transforaminal epidural injections; fair for spinal stenosis with caudal, interlaminar, and transforaminal epidural injections; and fair for post surgery syndrome with caudal epidural injections and limited with transforaminal epidural injections. • The evidence for therapeutic facet joint interventions is good for conventional radiofrequency, limited for pulsed radiofrequency, fair to good for lumbar facet joint nerve blocks, and limited for intraarticular injections. • For sacroiliac joint interventions, the evidence for cooled radiofrequency neurotomy is fair; limited for intraarticular injections and periarticular injections; and limited for both pulsed radiofrequency and conventional radiofrequency neurotomy. • For lumbar percutaneous adhesiolysis, the evidence is fair in managing chronic low back and lower extremity pain secondary to post surgery syndrome and spinal stenosis. • For intradiscal procedures, the evidence for intradiscal electrothermal therapy (IDET) and biaculoplasty is limited to fair and is limited for discTRODE. • For percutaneous disc decompression, the evidence is limited for automated percutaneous lumbar discectomy (APLD), percutaneous lumbar laser disc decompression, and Dekompressor; and limited to fair for nucleoplasty for which the Centers for Medicare and Medicaid Services (CMS) has issued a noncoverage decision. II. Cervical Spine • The evidence for cervical provocation discography is limited; whereas the evidence for diagnostic cervical facet joint nerve blocks is good with a criterion standard of 75% or greater relief with controlled diagnostic blocks. • The evidence is good for cervical interlaminar epidural injections for cervical disc herniation or radiculitis; fair for axial or discogenic pain, spinal stenosis, and post cervical surgery syndrome. • The evidence for therapeutic cervical facet joint interventions is fair for conventional cervical radiofrequency neurotomy and cervical medial branch blocks, and limited for cervical intraarticular injections. III. Thoracic Spine • The evidence is limited for thoracic provocation discography and is good for diagnostic accuracy of thoracic facet joint nerve blocks with a criterion standard of at least 75% pain relief with controlled diagnostic blocks. • The evidence is fair for thoracic epidural injections in managing thoracic pain. • The evidence for therapeutic thoracic facet joint nerve blocks is fair, limited for radiofrequency neurotomy, and not available for thoracic intraarticular injections. IV. Implantables • The evidence is fair for spinal cord stimulation (SCS) in managing patients with failed back surgery syndrome (FBSS) and limited for implantable intrathecal drug administration systems. V. ANTICOAGULATION • There is good evidence for risk of thromboembolic phenomenon in patients with antithrombotic therapy if discontinued, spontaneous epidural hematomas with or without traumatic injury in patients with or without anticoagulant therapy to discontinue or normalize INR with warfarin therapy, and the lack of necessity of discontinuation of nonsteroidal anti-inflammatory drugs (NSAIDs), including low dose aspirin prior to performing interventional techniques. • There is fair evidence with excessive bleeding, including epidural hematoma formation with interventional techniques when antithrombotic therapy is continued, the risk of higher thromboembolic phenomenon than epidural hematomas with discontinuation of antiplatelet therapy prior to interventional techniques and to continue phosphodiesterase inhibitors (dipyridamole, cilostazol, and Aggrenox). • There is limited evidence to discontinue antiplatelet therapy with platelet aggregation inhibitors to avoid bleeding and epidural hematomas and/or to continue antiplatelet therapy (clopidogrel, ticlopidine, prasugrel) during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic fatalities. • There is limited evidence in reference to newer antithrombotic agents dabigatran (Pradaxa) and rivaroxan (Xarelto) to discontinue to avoid bleeding and epidural hematomas and are continued during interventional techniques to avoid cerebrovascular and cardiovascular thromboembolic events. Conclusions Evidence is fair to good for 62% of diagnostic and 52% of therapeutic interventions assessed. Disclaimer The authors are solely responsible for the content of this article. No statement on this article should be construed as an official position of ASIPP. The guidelines do not represent "standard of care."

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An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Part II: guidance and recommendations.

https://rapm.bmj.com/content/rapm/43/3/225.full.pdf

Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications: Guidelines From the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain

Object Extensive decompression with laminectomy where appropriate is often still described as the method of choice in surgery for lateral recess stenosis. Nonetheless, tissue-sparing procedures are becoming more common. Endoscopic techniques have become the standard in many areas because of the advantages they offer in surgical technique and in rehabilitation. Transforaminal and interlaminar access provide 2 full-endoscopic (FE) techniques for lumbar spine surgery. The goal of this prospective randomized controlled study was to compare the surgical results for the FE technique via the interlaminar approach with those of the conventional microsurgical technique in patients with degenerative lateral recess stenosis. Methods A total of 161 patients with FE or microsurgical decompression underwent follow-up for 2 years. In addition to general and specific parameters, the following measuring instruments were used: visual analog scale, German version of the North American Spine Society instrument, and the Oswes...

Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study

The sympathetic trunk is sometimes damaged during the anterior and anterolateral approach to the cervical spine, resulting in Horner’s syndrome. No quantitative regional anatomy in fresh human cadavers describing the course and location of the cervical sympathetic trunk (CST) and its relation to the longus colli muscle (LCM) is available in the literature. The aims of this study are to clearly delineate the surgical anatomy and the anatomical variations of CST with respect to the structures around it and to develop a safer surgical method that will diminish the potential risk of CST injury. In this study, 30 cadavers from the Department of Forensic Medicine were dissected to observe the surgical anatomy of the CST. The cadavers used in this study were fresh cadavers chosen at 12–24 h postmortem. The levels of superior and intermediate ganglions of cervical sympathetic chain were determined. The distance of the sympathetic trunk from the medial border of LCM at C6, the diameter of the CST at C6 and the length and width of the superior and intermediate (middle) cervical ganglion were measured. Cervical sympathetic chain is located posteromedial to carotid sheath and just anterior to the longus muscles. It extends longitudinally from the longus capitis to the longus colli over the muscles and under the prevertebral fascia. The average distance between the CST and medial border of the LCM at C6 is 11.6 ± 1.6 mm. The average diameter of the CST at C6 is 3.3 ± 0.6 mm. Superior ganglion of CSC in all dissections was located at the level of C4 vertebra. The length and width of the superior cervical ganglion were 12.5 ± 1.5 and 5.3 ± 0.6 mm, respectively. The location of the intermediate (middle) ganglion of CST showed some variations. The length and width of the middle cervical ganglion were 10.5 ± 1.3 and 6.3 ± 0.6 mm, respectively. The CST’s are at high risk when the LC muscle is cut transversely, or when dissection of the prevertebral fascia is performed. Awareness of the CST’s regional anatomy may help the surgeon to identify and preserve it during anterior cervical surgeries.

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Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine

Object The purpose of this study was to compare the methods of posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF) in cases of isthmic Grades 1 and 2 lumbar spondylolisthesis, and to evaluate the clinical efficacy of the procedures. Methods Operations were performed in 50 patients with lumbar spondylolisthesis in the authors' clinics between 2001 and 2007. Indications for surgery were low-back pain with or without sciatica and neurogenic claudication that had not improved after at least 6 months of conservative treatment. The study included 33 female and 17 male patients, with mean ages of 50.6 years in the PLIF group and 47.3 years in the PLF group. These patients were randomly allocated into 2 groups: decompression, posterior transpedicular instrumentation, and PLF (Group 1; 25 patients) and decompression, posterior transpedicular instrumentation, and PLIF (Group 2; 25 patients). In the PLIF group, titanium cages were used, and autograft material was obtained from the decompression....

Posterior lumbar interbody fusion versus posterolateral fusion with instrumentation in the treatment of low-grade isthmic spondylolisthesis: midterm clinical outcomes.

AIM The study was conducted to compare the clinical effectiveness of FJ injections (FJI) and FJ radiofrequency (FJRF) denervation in patients with chronic low back pain. MATERIAL AND METHODS This study included 100 patients; 50 in FJI 50 in FJRF group. VNS, NASS and EQ-5D were used to evaluate the outcomes. All outcome assessments were performed at baseline, 3 months, 6 months and 12 months. RESULTS FJI in early post-op but FJRF in 1st, 6th and 12th month VNS showed better results (p < 0.001). There was no significant difference in the 1st (p=1) and 6th month (p=0.13) but in 12th month (p=0.04) in NASS. Increase in level number showed positive effect in NASS in FJRF group (p=0.018) but no effect in FJI group (p=0.823) in the 12th month follow-up. There was no significant difference with respect to 1st month (p=0.17), 6th month (p=0.22) and 12th month (p=0.11) post-procedure follow-ups in EQ-5D. At the short term FJI was more effective than FJRF however in midterm follow-up FJRF had more satisfying results than FJRF. CONCLUSION To our knowledge, the first choice should be the FJI and if pain reoccurs after a period of time or injection is not effective, RF procedure should be used for the treatment of chronic lumbar pain.

/pdf/comparison-of-effectiveness-of-facet-joint-injection-and-2wsb1bzi9h.pdf

Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain.

Brain abscesses have been one of the most challenging lesions, both for surgeons and internists. From the beginning of the computed tomography (CT) era, the diagnosis and treatment of these entities have become easier and less invasive. The outcomes have become better with the improvement of diagnostic techniques, neurosurgery, and broad-spectrum antibiotics. Atypical bacterial abscesses are more often due to chemotherapy usage in oncology, long life expectancy in patients with human immunodeficiency virus (HIV) infection, and immunosuppression in conjunction with organ transplantation. Surgical treatment options showed no significant difference with respect to mortality levels, but lower morbidity rates were achieved with stereotactically guided aspiration. Decompression with stereotactically guided aspiration, antibiotic therapy based on results of pus culture, and repeated aspirations if indicated from results of periodic CT follow-up scans seem to be the most appropriate treatment modality for brain abscesses. Immunosuppression and comorbidities, initial neurological status, and intraventricular rupture were significant factors influencing the outcomes of patients. The pitfalls and evolution in the diagnosis and treatment of brain abscesses are discussed in this study. (DOI: 10.3171/FOC/2008/24/6/E2)

/pdf/pyogenic-brain-abscess-4yi9ab7na9.pdf

Tufan Cansever

Papers

Surgical anatomy of the cervical sympathetic trunk during anterolateral approach to cervical spine

Posterior lumbar interbody fusion versus posterolateral fusion with instrumentation in the treatment of low-grade isthmic spondylolisthesis: midterm clinical outcomes.

Comparison of effectiveness of facet joint injection and radiofrequency denervation in chronic low back pain.

Pyogenic brain abscess.

Surgical Results of Large and Giant Pituitary Adenomas with Special Consideration of Ophthalmologic Outcomes